Medicare G-Codes and Functional Limitation Reporting

Every holiday season is a blur for me because it coincides with the annual end of year “scramble to support new CMS policies” event.  But this year really takes the cake. With the dust barely settled on the phasing of Manual Medical Review and my head still spinning from the recent Medpac recommendations, it is already time to turn my attention to the new claims based data-collection strategy, popularly known as the new G-Codes.

Before we describe G-Codes in any way, let me address our community’s anxiety by stating Clinicient is tailor made to support this kind of integrated reporting.  We will make this as easy for the therapist as possible.  In essence, therapists are being asked to report a functional limitation and assign a percentage of impairment at specific points within the episode of care.  This has to be translated into a set of G-Codes that can be submitted by claim.

You can expect Clinicient will automatically track the CMS requirements, prompt the therapist at the moment of documentation when reporting is needed, provide the therapist a simple pick list to record the information, and automatically include the appropriate G-code and modifier in the claim without any other intervention.  As complicated as the rule is, this can be made simple with the right system.

 

What are the G-Codes and why do they exist?

As part of the Middle Class Tax Relief Act of 2012, CMS committed to collect data on beneficiaries’ functional outcomes from therapy services provided.  This five (5) year project is intended to support payment reform with outcome based data.  This is strictly a data collection effort and no other uses beyond analysis have been published.

To collect the data, CMS is using the most convenient collection method at hand, namely claim submission.  Therapists are required to report Functional Limitations through a series of G-Codes (Gxxx8) and Modifiers (CX) at the outset of treatment, at least every 10 visits thereafter, and at discharge.

The G-Codes and modifiers must be present in both the medical record and the claim.  In particular, the medical record is supposed to show what tools and other information led to the values submitted on the claim form.

 

Who has to submit them?

All practice settings that provide outpatient therapy services billing under Medicare Part B must include this information on the claim form. Specifically, the policy will apply to physical therapy, occupational therapy, and speech therapy services furnished in hospitals, Critical Access Hospitals (CAH’s), Skilled Nursing Facilities (SNF’s), Comprehensive Outpatient Rehabilitation Facilities (CORFs), rehabilitation agencies, home health agencies (when the beneficiary is not under a home health plan of care), and in private offices of therapists, physicians and nonphysician practitioners.

 

When do I have to start submitting?

CMS has directed the Medicare Administrative Contractors (MACs) to begin accepting G-Codes on January 1, 2013, but January 1st through June 30th is really an extended testing period.  Beginning July 1, 2013 any claim without the G-Code functional limitation data will be denied.

In my next blog post, I will cover Medicare G-codes and how they work, how you report the measures and what is critical to remember.

 

To learn how Clinicient makes Functional Limitation Reporting Easy, click here. 

Download Free G-Codes Cheat Sheet: 


On-Demand PQRS Webinar: 


View a complimentary webinar with physical therapist Jerry Henderson and Keddrick Stuart.

Jerry provides therapists with an overview of functional limitation requirements, what is required of  therapists and when, and provides case studies of exactly how to use g-codes and severity modifiers according to functional limitations and treatment goals. A short demonstration is also provided to illustrate how the codes carry through on claim creation and eliminate billing risks that could increase audit risks.

 


Click Here to Visit our Functional Limitation Reporting Resource Page

 

 

 

 

 

 

22 Comments

  1. Angela
    Posted December 12, 2012 at 6:59 pm | Permalink

    We see 99% pediatric patients and right now are not filing Medicare Part B… however, we do file Kentucky Medicaid for our Michelle P Waiver patients. Is Medicaid requiring the G-codes, or just Medicare? Thank you

    • Keddrick Stuart
      Posted December 29, 2012 at 5:54 pm | Permalink

      Angela,
      This is strictly a CMS Medicare effort to gather data to support changes to payment policy in the future. No Medicaid is heading this direction at this time

  2. Laurie Goshe
    Posted December 12, 2012 at 11:03 pm | Permalink

    I am looking for a list of the G codes and Severity codes the will be used in Medicare Physical Therapy documentation and in billing.
    I attended the audio seminar 12/12/12, but they did not provide the list of these codes for us and the link /web site they suggested does not have them either.
    Can you provide me with the list???
    Xotcmrldii@aol.com
    Thank you
    Laurie Goshe PT

  3. CM White
    Posted December 27, 2012 at 7:29 pm | Permalink

    We see about 35% Medicare patients in our practice and with the amount of nonpayable time and effort CMS is asking of Physical Therapists, I believe this is going to result in many therapist not accepting Medicare patients any longer. The government has gone too far this time…..

  4. Posted February 27, 2013 at 9:42 pm | Permalink

    Appreciate it for helping out, superb info .

  5. marilyn
    Posted February 28, 2013 at 6:55 pm | Permalink

    If you see a patient on her 9th visit and you use the g codes then because she has improved. When do you use the g codes again?
    Do you do use them on every 10th visit from then on? Saying she isn’t being dismissed yet from Physical Therapy.

    • Keddrick Stuart
      Posted March 7, 2013 at 1:23 am | Permalink

      What you are saying is that in essence you did a progress note on the 9th visit and submitted the G-codes at that moment. Then you need to submit another progress note by the time another 10 visits go by.
      Your MACs are starting to publish their policies on this, so I would definitely look to them for clarification. There is often some difference by MAC in the implementation of policy.

  6. Janine
    Posted April 9, 2013 at 6:33 pm | Permalink

    do we need to document the G-codes for the Medicare HMO accounts too? (like Humana, BC, Anthem’s Medicare HMO products??)

    • Nicole
      Posted June 27, 2013 at 3:50 am | Permalink

      I am looking for the same answer.

  7. Posted June 5, 2013 at 7:50 pm | Permalink

    do we need to apply the g & c codes to patients that were evaluated prior to 7/1/13?

    If you could answer this question I’d appreciate it.

    Deb Tuckner
    Regina Medical Center
    Orthopedic & Sports Therapy Dept
    Hastings, MN 55033

    • Clinicient
      Posted June 7, 2013 at 10:31 pm | Permalink

      Hi Deb,

      Great question. You should begin reporting Functional Reporting Classifications (G Codes) and Impairment Ratings for ALL of your existing Medicare patients on the next visit, and submit claims on those patients with the FLR Codes for testing. In addition, we are recommending that you update all of the Impairment Ratings for your existing Medicare patients on the first visit on or after July 1st, just to make sure that you do not get any claims rejections. Please let us know if you have any additional questions.

      Best,
      Clinicient

  8. Kathy Carrier, PT
    Posted June 26, 2013 at 3:04 pm | Permalink

    We did not see a response to the above question if we have to use the G Codes for Humana Medicare, Medicare Advantage, Medicare Plus Blue, etc. Could you please answer this question for us? Thank you

  9. Nicole
    Posted June 27, 2013 at 3:49 am | Permalink

    Do we have to report G-Codes for Medicare Advantage Plans, for instance Keystone 65 etc.. And do we report G-Codes when Medicare is secondary.

  10. KL
    Posted July 1, 2013 at 8:26 pm | Permalink

    Medicare does not require Functional Reporting for Medicare Advantage Plans. However, providers should check with their plan to determine if the plan imposes requirements.

    http://www.cms.gov/Medicare/Billing/TherapyServices/Downloads/Functional-Reporting-PT-OT-SLP-Services-FAQ.pdf

  11. mimi johnson
    Posted September 6, 2013 at 12:22 am | Permalink

    Does the therapist add the G-codes in their documentation, then the coders from health information add this to the chart for billing?

  12. Posted September 16, 2013 at 7:35 pm | Permalink

    Is BCBS starting to require the G codes for their Medicare Advantage plan 10/1/13.

    • Clinicient
      Posted September 20, 2013 at 4:34 pm | Permalink

      Hi Jean,

      Some Medicare Replacement plans are requiring Functional Limitation Reporting. It is always important to check the providers website for clear instructions, but several plans do require it, including some of the BCBS payers.

      Best,
      Clinicient

  13. Bonnie Greenough
    Posted October 23, 2013 at 2:07 pm | Permalink

    can you please explain which g code I would use when my internal medicine dr is following up after a hospitalization?

  14. Melissa
    Posted November 1, 2013 at 2:25 am | Permalink

    Do the G codes need to be reported for every date of service? And do you need more than one G codes per episode?

  15. Brindha Agilan
    Posted November 14, 2013 at 5:44 pm | Permalink

    hi
    i have couple of questions
    1) is that claim form same for all organisations (out patient, SNF, independent set ups)
    2) can a licensed PTA or Temporary permit PT fill the form or only a licensed PT is eligible to do it?
    kindly respond
    thanks,
    yours in health
    Dr. Brindha Agilan DPT

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